Inspection
No deficiencies recorded in this report
PACIFIC CARE HOME V
1790 BROOKS ST, San Mateo CA 94403
6 bedsLatest official report Apr 28, 2026Licensed
Additional info
- Telephone
- (650) 315-2152
- Licensee
- J & I LLC
- Administrator
- ANDAYA, MODDIE
- Contact
- ANDAYA, MODDIE
- License first date
- May 28, 2020
- License effective date
- May 28, 2020
- District office
- SAN BRUNO RO · (650) 266-8800
- Regional office
- 14
- Clients served
- 983 - RCFE / DEMENTIA
Summary
The available records show 2 Type A and 2 Type B deficiencies for this facility.
- Most recent inspection
- Apr 28, 2026
- Most recent deficiency
- May 3, 2024
2 later reports, from Apr 10, 2025 through Apr 28, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 150 San Mateo County facilities licensed for 6 or fewer beds.
In the available public five-year record, CCLD published 4 reports for this facility: 4 inspections, 0 complaint investigations, and 0 licensing or administrative records.
Those records contain 2 Type A and 2 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 4
- Recorded deficiencies
- 4
- Type A deficiencies
- 2
- Type B deficiencies
- 2
- Substantiated complaints
- 0
- Repeated topics
- 0
About the same as most this size
1 in the last 12 months
About the same as most this size
0 in the last 12 months
More than the typical 1
0 in the last 12 months
About the same as most this size
0 in the last 12 months
Most this size also have none
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
No topic repeats in the last 36 months
No deficiency topic appears in more than one report during that window. This does not establish that nothing repeated earlier in the five-year record, and it is not a statement about current conditions.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Inspection
No deficiencies recorded in this report
Inspection
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(2)
- Regulation authority
- CCR
What the official deficiency says
INCIDENTAL MEDICAL CARE Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met, as hall cabinet where medications are secured is unlocked upon LPA's arrival. Also, Clearlas for client 2 & Miralax for client 5 are stored in unlocked kitchen cabinet. Licensee failed to ensure that medications are inaccessible to clients, which poses an immediate health and safety risk to clients in care.
Official plan of correction
Medications cabinet was locked and Miralax and Clearlax were secured in medications cabinet in LPA's presence. Deficiency corrected and cleared.
Deadline recorded: May 3, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 3, 2024
Correction not verified in available records
Background checksType A
- Official classification
- Type A
- Official code
- 87355(e)(2)
- Regulation authority
- CCR
What the official deficiency says
CRIMINAL BACKGROUND CLEARANCE All individuals subject to a criminal record review pursuant to HSC 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met, as staff #1 does not have criminal record clearance associated to this facility. Licensee failed to ensure that all staff have criminal record clearance associated to facility, which poses an immediate health and safety risk to clients in care.
Official plan of correction
Request to transfer criminal record clearance for staff #1 and photo ID are given to LPA for processing. Deficiency corrected and cleared
Deadline recorded: May 3, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 3, 2024
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(c)(1)
- Regulation authority
- CCR
What the official deficiency says
PERSONNEL REQUIREMENTS Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met, as staff #1 and #2 do not have current first aid training. Licensee failed to ensure that caregivers have current first-aid training, which poses a potential health, safety, or personal rights risk to clients in care.
Official plan of correction
Proof of current first aid training for S1 and S2 will be sent to CCLD BY DUE DATE
Deadline recorded: May 17, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 17, 2024
Correction not verified in available records
Inspection
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(b)(15)
- Regulation authority
- CCR
What the official deficiency says
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 1 out of 3, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/15/2024 Plan of Correction Licensee to send copy of pre-admission appraisal and appraisal to LPA by POC due date.
Plan of correction recorded
Correction not verified in available records
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology